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How we think of the health system, which has of late been judged by its cost as a market good, but is increasingly judged on its merits as a public good (as demonstrated by patients' bill of rights efforts).

How we define health, which has moved from counting causes of disease or deaths to a view that encompasses quality in physical, social, and mental health. This is influenced by determinants such as social and physical environment, genetic endowment, individual lifestyle/behavior, and access to healthcare.

Who we are, particularly as the population ages. The aging population will increase the number of people with health needs, while the number of people in the workforce (including the healthcare workforce) shrinks.

How we organize to assure health. It is now expected that the health system will accommodate the broader definition of health by promoting optimal health status (not just interrupting disease).

To deal with these changes, Mr. Atchison asserted, "we need to get our acts together" to develop models of delivering essential public health services that work from within the communities served. Iowa's approach involved the development of Community Empowerment Areas designed to re-orient public policy toward supporting community leadership in the establishment and pursuit of visions and goals for improving Iowans' quality of life. The State's Empowerment Law was implemented by the heads of the Departments of Health, Education, and Human Services. The new model—focused on early childhood education—emphasizes:

Community leadership.

De-categorized funding.

Administrative simplification.

Interventions that are results-driven, with attention paid to both outcome and process measures.

The Empowerment Outcomes chosen were:

Healthy children.

Children who are ready to succeed in school.

Safe and supportive communities.

Secure and nurturing families.

Secure and nurturing child care environments.

Joseph Betancourt stated that racial/ethnic minorities comprise an increasingly large part of this country's population. Racial/ethnic disparities can be seen in both health outcomes and in healthcare utilization. This is demonstrated in infant mortality, influenza and pneumonia death rates, cancer death rates, cardiovascular disease death rates, diabetes-related death rates, and HIV/AIDS case rates. (Dr. Betancourt noted that there is wide variation within different racial/ethnic categories with regard to both health status and care access.) Within Medicare there is differential utilization based
on race for mammographies, amputations, influenza vaccinations, lung cancer surgeries, and renal transplants. The President's Initiative on Race has stated a goal of eliminating racial/ethnic disparities by 2010 in infant mortality, immunizations (child and adult), cancer screening and management, cardiovascular disease, diabetes, and HIV/AIDS.

Barriers leading to disparities include both social and healthcare determinants. Social determinants are outside the control of the healthcare system, such as socioeconomic status, violence, poor education, unsafe housing, and occupational hazards. Health organizations need to build partnerships with entities outside the healthcare system in order to minimize social barriers. Healthcare determinants can be addressed by the health system. These include:

Organizational barriers, such as the lack of diversity (including diversity of perspectives) in leadership and the workforce. This results in policies, procedures, and care providers not equipped to care for diverse client populations. Effects include difficult intake processes and long waiting times. These barriers can be minimized through diversity in recruitment and training of the leadership and workforce. A good example is New York's Medicaid managed care program. Mr. Atchison added a note on the importance of working early in the educational system, for example, by recruiting more minority teachers and professors. Dr. Betancourt noted that there can be a disconnect between providers and racial/ethnic minorities regarding the level of effort being made to recruit minority workers.

Systemic barriers, in which systems are not constructed to deliver quality care to diverse client populations. The results are lack of interpretation services, culturally specific health education materials, telephone services, and transportation. Effects include poor communication and less adherence to health promotion/disease prevention. These barriers can be minimized through the creations of systems for culturally diverse populations. California's Medicaid managed care program has made promising efforts in these areas.

Provider-based barriers, in which providers are not trained to understand sociocultural variations in health beliefs and behaviors. This results in a lack of understanding and poor communication between providers and clients. Effects include poor adherence to diagnostic and treatment regimens and health promotion/disease prevention interventions. Massachusetts' Medicaid managed care has done some provider training.

Future directions in dealing with racial/ethnic disparities include:

Data collection: Collecting data by race/ethnicity is critical for determining the root causes of disparities and looking at quality measures and improvement but is full of challenges. Many entities believe that it is illegal and racist to collect this data, which is untrue. There are also challenges in determining appropriate sample size and in oversampling. New ways of collecting such data may need to be developed.

Public-private partnerships: For example, in New York, the Office of Civil Rights, the hospital association, the doctors' and nurses' societies, and public health experts have convened to develop strategies to raise awareness and eliminate disparities.

Federal-State collaboratives: For example, the Health Care Financing Administration is working with States to target certain disease areas.

Community involvement: This is critical for successful efforts. Developing trust is a serious issue that requires developing a track record of efforts that show results (even if these are simple things at the start).

Both presenters touched on the impact of genetic research, which holds great promise, but which will provide services that will probably be extremely expensive. Mr. Atchison stated, "Genetic research presents the single greatest challenge to our ethical construct in a long time. There are many potential implications, and we as a society need some kind of mechanism to work through them in a rational manner through public discourse." Dr. Betancourt noted, "There will probably be an incredible genetic divide. Right now, racial and ethnic minorities can't even get mammograms."